Social Anxiety Disorder- What It Is And How To Treat It

Hello, I’m Dr. Carlo Carandang and I’m a psychiatrist with AnxietyBoss.com. Today, I will talk about social anxiety disorder, also known as social phobia. Social anxiety disorder (SAD) is an anxiety disorder where you have excessive fear of social scrutiny and you avoid social situations. So the audience will benefit from this presentation by learning more about SAD and how they can treat it.

SAD Facts

So here are some facts about SAD: the lifetime prevalence of SAD in the population is 5%- so in other words, in the general population, 5% of people at any point in their lifetimes will have developed social anxiety disorder. So this is a fairly common disease in the general population, where 5% will have developed social anxiety at any point in their lifetimes. Interestingly, over 80% of people with social phobia do not receive treatment and the average age when individuals first seek treatment is 27.2 years.

So in other words, the majority of people with social anxiety disorder do not receive treatment and if they do finally receive treatment they receive it well into adulthood and into their late 20’s. Those at increased risk for developing SAD include Native Americans, young people, people with low-income. Social anxiety disorder also tends to co-occur with other disorders such as generalized anxiety disorder, bipolar disorder, avoidant personality disorder, and dependent personality disorder.

SAD Symptoms

So now we are going to talk about SAD symptoms. In social anxiety disorder, you have an excessive fear of social or performance situations where embarrassment may occur. So in SAD, you have a fear of social situations. For instance, you might avoid crowded places such as going to the mall or to the grocery store, as you are fearful that other people are just going to make fun of you or that you may just embarrass yourself.

There is a subtype of social anxiety disorder called performance anxiety, where you have a fear of performing in front of people. Performance anxiety is also called stage fright. So when you have stage fright you have a fear of speaking or performing in front of an audience, as you are afraid of embarrassing yourself, or that the audience will make fun of you. So with performance anxiety or stage fright, you might have a fear of playing music in front of people or speaking in front of people or singing in front of people- this is called performance anxiety or stage fright, which is a subtype of social anxiety disorder.

Other people with SAD might have a fear of being observed while they’re eating or drinking, as they are afraid that doing so will embarrass them and people will make fun of them. Also, exposure to social or performance situations brings about an anxiety response, so that these situations are avoided. So when you have social anxiety disorder, you avoid social situations or performance situations at all costs, because when you are exposed to the social situation or the feared performance situation, this brings about an anxiety response where you might actually have a panic attack. So social situations and performance situations are avoided at all costs, if you have social anxiety disorder.

SAD Diagnosis

So how do you diagnose social anxiety disorder? In addition to these symptoms of social anxiety or performance anxiety and the avoidance of social or performance situations, to qualify as social anxiety disorder, these symptoms have to interfere with your life and disrupt your functioning. So not only do you have to have the previously mentioned symptoms of social anxiety or performance anxiety, you also have the avoidance of these situations and it has significant impact on your life, where it disrupts your functioning. So what happens is that social anxiety starts to make you homebound.

So pretty soon when you start avoiding social situations, and when you start avoiding performance situations, what happens is that you start to become homebound. You might call in sick from work as you don’t want to give your presentation to your co-workers as you have an important project to present. So what happens is that when you have social anxiety or performance anxiety, you start to avoid these social and performance situations to the point where it starts disrupting your life. So maybe you’re at risk for being fired as you can’t go to work and present your projects, or you might have relationship problems because you’re so anxious to go out of your home that you can’t connect with your friends and family. So this is what I mean by making a diagnosis of social anxiety disorder, it has to have significant impact on your life and functioning.

SAD Clinical Course

Next we will discuss the clinical course of SAD. Social anxiety disorder starts at an average age of 15.1 years, and it lasts an average of 16.3 years. In other words, social anxiety disorder starts in adolescence and it lasts a long time. Most people with social anxiety disorder report performance anxiety, so most people with SAD have stage fright.

SAD Development

So how does social anxiety disorder develop? Well, we can look at this negative cycle of social phobia to tell us how social anxiety develops. So let’s say you have to give a presentation to your coworkers. So what happens is is that if you are prone to social anxiety, then this presentation to co-workers triggers you. This situation induces thoughts about the event, so you might have thoughts about the presentation that “everyone will make fun of me;” “they will think I’m stupid;” “I will embarrass myself” and “they will not like me.”

These thoughts then induce anxiety, where you are anxious, fearful, and self-conscious. You may also have physical sensations of the anxiety from the adrenaline response, such as increased heartbeat, increased breathing, shortness of breath, lump in the throat, and butterflies in the stomach. So these are the physical sensations of anxiety that you might develop when you’re speaking in front of people: the butterflies in the stomach, the lump in the throat, or the trembling knees and legs. So what happens is that these anxiety symptoms then make make you want to avoid these social and performance situations. You avoid the performance situation and you try to get out of presenting to your co-workers. Maybe you call in sick, or if you do go, you delay it. However, if you do go and if you decide to go present your co-workers, you might avoid eye contact, you might not talk, you might hide, you might actually drink if there’s alcohol available, or you might just plan your escape. When you’re giving a presentation you might even do the unthinkable, where you become paralyzed and you can’t speak or move.

So what happens then is that when you start to avoid these performance or social situations, this then maintains the belief that people are making fun of you and you never get to find out that if you just go and just relax and focus on the task at hand that you can give a presentation to your co-workers and your worst fear will not come to fruition. However if you avoid giving presentations or avoid social situations, you never get to find out that your fear never really comes about that people are making fun of you, when in fact, what they’re looking for is a good presentation and they want to be knowledgeable about what you have to offer in your presentation. So this avoidance then maintains the belief that people are making fun of you and then this maintains the negative, vicious cycle of social phobia.

As you see here in the middle of this negative cycle of social phobia, you have this extreme self-focus. So you’re so focused on yourself, thinking that people are making fun of you, that you look funny, that maybe you’re stupid. So what happens is that as you get into this negative vicious cycle of social phobia that you become to self-focused, when in fact people are really looking at you and evaluating you based on your content and what you have to deliver, instead of all the traits that you are worried about.

SAD Neurobiology and Family History

So let’s talk now about the neurobiology and family history of social anxiety disorder. In social phobia, there is an increase of activity in the amygdala. So the amygdala is the fear and anxiety center of the brain, and this is where fear and anxiety is mediated in social anxiety disorder. There may also be a disruption of the brain circuits which connect the prefrontal cortex and limbic region which includes the amygdala.

Social anxiety disorder also runs in families. So in other words, you can get social anxiety disorder from your parents, both from genetic factors and from environmental factors. So your parents might give it to you as they pass it down to you from their genes. Also, they might model it for you by acting in ways that make you prone to social anxiety disorder. For instance, if they have these negative attributions about social situations that they might think people are making fun of them or that they might embarrass themselves, then they get anxious and then they start avoiding. So once you start observing how they react to social situations, you, in turn, as the offspring might emulate the way they think and avoid social situations that you are also at risk for social anxiety disorder. The environmental factors also piggybacks on the genetic factors where you might actually just be prone to it anyways because you inherited the genes from your parents. So the combination of modeling from your parents and the social anxiety genes you inherited from your parents make you at high risk for developing social anxiety disorder.

SAD Treatment

So how do you treat social anxiety disorder? Well, the first line of treatment for social anxiety disorder is cognitive behavioral therapy, also known as CBT. The great thing about CBT is that it lasts longer than pharmacotherapy. Pharmacotherapy is prescription medication treatment for social anxiety disorder. However, CBT is first line treatment. So when you have social anxiety disorder, CBT is the treatment that should be tried first, and if you have a positive response to CBT, then the effects will last longer then say if you chose to do medication treatment. So the benefit of psychotherapy is that it lasts longer than medication treatment.

So let’s say you do not to respond to CBT. If CBT is not effective for your social anxiety disorder, then your doctor might prescribe you a medication treatment. So prescription drug treatment for social anxiety disorder is last resort treatment. To repeat, medication treatment is for cases where CBT is not effective, or if you have a severe case of SAD. If this is the case, then your doctor may go ahead and prescribe you medications that are effective for SAD, which include selective serotonin reuptake inhibitors, also known as SSRIs, and serotonin norepinephrine reuptake inhibitors, also known as SNRIs.

Your doctor may also choose to treat your SAD with benzodiazepines. However, benzodiazepines are generally not recommended for SAD. It’s not recommended for SAD, given that this anxiety disorder has a chronic course and needs long term treatment. In addition, benzodiazepines have an addictive potential and if the anxiety is severe then the benzodiazepine can be prescribed on a short-term basis until the SSRI or SNRI takes effect a few weeks later. So really the the main role for benzodiazepines and SAD would be to prescribe it to be to taken on a short-term basis, until the SSRI or SNRI that your doctor is prescribing takes effect a few weeks later. Then after the SSRI or SNRI becomes effective, then the benzodiazepine can be tapered and eventually discontinued.

The issue with SSRIs and SNRIs is that they may initially increase agitation and anxiety, so this might happen in the first week or two of SSRI or SNRI treatment. To combat this side effect of SSRIs and SNRIs, in which it causes an increase in anxiety and activation during the first couple weeks, your doctor may prescribe a benzodiazepine to help calm both your anxiety and your activation from the SSRI or SNRI. In three to six weeks, once the SSRI or SNRI becomes effective and your anxiety comes down, then at that time your doctor may then taper and eventually discontinue your benzodiazepine.

The problem with benzodiazepines is that if you take it for more than a couple of months, then you start to become dependent on it, and then what happens is you might be taking more and more of it. Pretty soon you become addicted to the benzodiazepine, which is not a good, and then you get a separate problem than the problem that you were originally prescribed the benzodiazepine in the first place. So not only do you have an anxiety disorder- you now also have an addiction to benzodiazepines. So again, benzodiazepines are only meant to be prescribed short-term, and only until the SSRI or SNRI takes effect a few weeks later. At that point, the benzodiazepine can be discontinued.

Performance Anxiety Treatment

Performance anxiety is a subtype of social anxiety disorder, and people that have performance anxiety only have the anxiety when they have to perform in front of an audience. So people with performance exactly don’t necessarily have social anxiety, as people with performance anxiety (stage fright) can go to malls, they can go to public places, and they can go to crowded places because they’re not performing in front of them. So their real fear is when they perform in front of an audience, and it’s not about exposing themselves socially to other people.

In performance anxiety situations, SSRIs, SNRIs, and benzodiazepines are not preferable. What’s effective for performance anxiety (stage fright) during these discrete situations where you have to give a performance are beta blockers like propranolol. Propranolol is commonly prescribed for hypertension in adults, but is also prescribed for for people with stage fright. So when you are only anxious when you have to give a speech or perform in front of people, then your doctor can prescribe you propranolol 25mg to 50mg, about 30 minutes to an hour before your scheduled performance. So when you take the propranolol right before your performance, what happens is that it prevents your heart rate from going up and prevents you from breathing faster. Basically, propranolol prevents the physical symptoms of anxiety from coming up when you are performing in front of people, so that you can go through the performance without being paralyzed or having an anxiety attack. So beta blockers are taken on an as-needed basis about 30-minutes to an hour before the scheduled performance. About 25 to 50 milligrams is the usual dosage, and that should last you for up to an hour during the performance, so that it prevents the physical manifestations of the anxiety attack.

SAD Alternative Treatments

There are alternative SAD treatments, and these include exercise, progressive muscle relaxation, diaphragmatic breathing, meditation, yoga, tai chi, massage, and martial arts. So these interventions can help to decrease your overall anxiety levels. However, let me emphasize that these alternative SAD treatments are not meant to be primary treatments, but only meant to augment the primary treatments, which are CBT and/or prescription drug treatment. These alternative SAD treatments can be used to augment the primary treatment of SAD. as these alternative treatments can then lead to an overall decrease of your anxiety levels. To repeat, these alternative treatments are not meant to be used as primary treatments.

If you dislike the side effects and expensive costs of prescription medications, then natural supplements are a great alternative, as they are safe, effective, natural, and less expensive. So there are multiple studies that show that several different natural supplements are effective and safe for anxiety disorders such as SAD. Natural supplements generally have fewer side effects and are generally less expensive than prescription medications for anxiety. So in the next few years you’re going to see more and more natural supplements with research studies showing that they’re effective for SAD. People eventually may want to try these natural supplements, as they are natural, and not synthetic or man-made like the prescription drugs that doctors prescribe.

Other SAD treatments include self-help interventions. Research has shown that self-help interventions are effective tools for social anxiety disorder, and self-help interventions are convenient, can be done on your own time, do not require a doctor visit, do not require a therapist visit, and are relatively inexpensive.

SAD Summary

In summary, social anxiety disorder is characterized by excessive fear of social scrutiny and avoidance of social situations. The good news is that SAD has effective treatments which include CBT as first-line treatment and prescription medications as last resort treatment. Alternative treatments include exercise, progressive muscle relaxation, diaphragmatic breathing, natural supplements, and self-help interventions. These alternative treatments have preliminary evidence that they are both effective and safe for anxiety disorders such as SAD.

For more information about social anxiety disorder and other anxiety problems, please visit the rest of AnxietyBoss.com.

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About Dr. Carlo

Dr. Carlo Carandang is a psychiatrist, anxiety and depression expert, and founder of AnxietyBoss.com. He has seen patients with anxiety and depression for over 15 years. Dr. Carlo has been a Fellow of the American Psychiatric Association since 2010, was Board Certified in Psychiatry in 2002, and has been licensed as a physician in Washington State since 1998. He is also a data scientist focused on machine learning and AI, especially for healthcare applications.